1. Fractures of the Pelvis and Acetabulum in the Pediatric Patient Not your typical pediatric fracture
John T. Riehl, MD
Updated August 8, 2016
Acknowledgement and special thanks to the OTA archives, Joshua Klatt, Steven Frick, and Wade Smith for assistance with images and content

2. Objectives
To highlight differences between adult and pediatric pelvic and acetabular fractures
To discuss initial management of pelvic and acetabular fractures
To discuss surgical treatment indications for pediatric pelvic and acetabular fractures
To discuss complications related to pediatric pelvic and acetabular fractures

3. Pelvic Fractures

4. Background 2.4-7.5% of all childhood fx’s High energy injuries
Most often stable fx’s (90%)

5. Pediatric Vs. Adult Pelvic Fx
Elastic joints (symphysis & SI)
Avulsion fx’s common
Remodeling?
Mechanism
ped vs auto
Passenger
Fall from height
Child abuse
Severe intrapelvic injury with nondisplaced fx’s (less common)
Adult
Inelastic joints
Fx commonly in > 1 place (hard pretzel)
Mechanism
High energy vs low energy
MVC
Fall from standing
Intrapelvic content injury often accompanied by severe displacement
Schlickwei W, Keck T. Pelvic and acetabular fractures in childhood. Injury. 2005; 36(suppl 1):A57-A63.

6. Pediatric Vs. Adult Pelvic Fx
Poorly defined
When is pelvis pediatric vs. adult?
< 18?
Open triradiate?

7. Pediatric Considerations
Ligaments stronger than bones
High incidence of LC2/LC3: crescent fractures
Increased incidence of Open Frxs
Increased incidence open fx’s compared to adults with pelvic fx
Slide courtesy of Wade Smith, MD

8. Initial Evaluation & Management
Trauma protocol (ATLS/PALS)
Airway, breathing, circulatory status
Life-threatening injuries
C-spine immobilization
Comprehensive neurologic exam
Mechanism of injury
Medical & surgical history

9. Initial Evaluation & Management
Visual inspection
Pelvis, perineum, scrotum/ vagina for ecchymosis, lacerations
May not be obvious
If urethral injury suspected  retrograde urethrogram
Log roll
Palpation
ASIS, symphysis, crests, SI joints
Hip ROM
Treat/prevent hypothermia
Picture courtesy of Wade Smith, MD

10. Open Pelvis Fractures Cover wounds in ED Antibiotics/ Tetanus
Explore in the OR!
Historically 20-50% mortality
Aggressive I&D
Stabilization
Diverting colostomy
Slide courtesy of Wade Smith, MD

11. Diagnostic Tests When fx present, consider CT scan, inlet, outlet
When stable
Routine Trauma AP pelvic XR
May not need if:
GCS > 10
HD stable
No SCI
Negative pelvic exam
No hematuria
May not need to get AP pelvis in all pediatric trauma patients if they meet the above criteria. Additional imaging should be done only after patient is stable.

12. Diagnostic Tests Pelvic obliquity Keshishyan et al
Difference in length border SI to triradiate
Pelvic asymmetry if > 4 mm difference
Keshishyan RA, et al. Pelvic polyfractures in children. Radiographic diagnosis and treatment. Clin Orthop Relat Res Nov;(320):28-33.
Image courtesy of Wade Smith, MD

13. Initial Management Similar to adults: Rapid identification
Resuscitation
Mechanical Fixation where indicated
Angiography/PPP
Pictures courtesy of Wade Smith, MD

14. Mechanical Stabilization
Function
Splint/stabilize bone
Splint soft tissues
Decrease/stabilize
pelvic volume
Decrease pain/catecholamines
Protect blood clot

15. Mechanical Stabilization
Keep It Simple!
Pelvic wrap, binder
Broad surface area
Tape legs together
External fixation
Resuscitation clamp
Allow access for laparotomy
Skeletal traction
Slide adapted from Wade Smith, MD

16. Ex Fix Considerations in the Pelvis
Simple frames
Pin location
Iliac Crest frames
Anterior (AIIS) frames
Uses flouro/OR
Provide poor posterior control
Wasting time?
Should time be spent initially in IR for embolization vs OR for external fixation?
Is embolization all that is needed for initial hemodynamic stabilization, and should we just skip to performing definitive stabilization in pelvic fx’s?

17. Fx Classification Torode & Zieg Tile Type 1 Type 2 Type 3 Type 4
avulsion fx
Type 2
iliac wing fx
Type 3
“simple” ring (anterior)
Type 4
Ring disruption (bilateral rami, SI joint)
Unstable
Tile
Type A
Stable
Type B
Unstable rotationally
Incomplete posterior disruption
Type C
Unstable vertically and rotationally
Complete posterior disruption

18. Torode & Zieg ClassificationII
III IV

19. Tile Classification Applicable in patients near skeletal maturity
More often adult type patterns
Type A – Stable
Type B – Rotationally unstable, vertically stable
Type C – Rotationally and vertically unstable

20. Secondary Ossification Center
Iliac Crest : first seen at age 13 to 15 and fuses at age 15 to 17 years
Used in Risser staging
Ischium : first seen at age 15 to 17 and fuses at age 19 to 25 years
ASIS : first seen about age 14 and fusing at age 16
*Important to know these secondary ossification centers so they will not be confused with avulsion fractures
Slide courtesy of Joshua Klatt , MD and Steven Frick, MD

21. Relative Percentages of Pelvic Avulsion Fracture Locations
Fx’s occur through apophysis (Torode I)
Ischial tuberosity – 54%
AIIS – 22%
ASIS – 19%
Pubic Symphysis – 3%
Iliac Crest – 1%
Forceful contraction of muscles cause fx at attachment sites
Rossi F, Dragoni S. Acute Avulsion Fractures of the Pelvis in Adolescent Competitive Athletes. Skeletal Radiol. 2001;30(3):
Slide adapted from of Joshua Klatt , MD and Steven Frick, MD

22. Examples of Avulsion Fx’s
Images courtesy of Journal of Orthopaedic Trauma, Joshua Klatt , MD and Steven Frick, MD

23. Pediatric Pelvic Fractures Require Surgery Sometimes Too!
Watts, 1976: 66 peds/trauma deaths- 42% died of pelvic fracture/exsanguination
Bucholz (’82), Ebraheim (94’), Torode (’85): 30% of survivors have residual impairments
Few articles but differing conclusions regarding effect of surgery on outcome

24. Treatment Indications for operative treatment Open pelvic fx
Instability (Torode 4, Tile C)
Displacement > 2 cm
>1 cm pelvic asymmetry?

25. Treatment Smith et al. JBJS, 2005, pp 2423-2431
All patients had open triradiate cartilage and unstable pelvic fx
6 yr f/u
Short MSK Function Assessment (SMFA)
Pelvic asymmetry did not remodel
All pts with > 1.1 cm pelvic asymmetry had at least 3/4:
nonstructural scoliosis
lumbar pain
Trendelenburg gait
SI tenderness

26. Treatment Summary by Torode Classification
Torode & Zieg 1
Symptomatic
Protected WB 4 wks
Stretch & strengthen
Torode & Zieg 2
Torode & Zieg 3
Symptomatic
Protected WB 6 wks
Torode & Zieg 4
Bedrest/Symptomatic +/- traction (< 2 cm displacement)
> 2 cm displacement  fix
Ex-fix (rotation)
ORIF
Percutaneous

27. Complications Nonunion Instability Malunion Leg-length inequality
Low back pain
Myositis ossificans
Neurologic defects
Nonunion and instability are not often major longterm problems. Malunion, leg length inequality, and the complications thereof are more common.

28. Complications Study of German Trauma Registry
208 pediatric pelvic fx’s compared to 13,317 adults
No cases in children of
VTE
ARDS
MOF
Zwingmann J, et al. Pelvic fractures in chldren results from the German pelvic trauma registry: A cohort study. Medicine (Baltimore) 2015 December; 94(51): e2325.

29. Acetabular Fractures

30. Background Uncommon 1-15% of pelvic fractures
Even less literature than ped pelvic fx
Most often in adolescents
Image courtesy of Joshua Klatt , MD and Steven Frick, MD

31. Background High energy injury mechanism most common
Triradiate cartilage
In younger pts, fx’s through triradiate can occur with lower injury mechanisms
Image courtesy of Joshua Klatt , MD and Steven Frick, MD

32. Pediatric Vs. Adult Tab Fx
Elastic joints
Remodeling?
Growth arrest
Mechanism
ped vs auto
Passenger
Fall from height
Child abuse
Pattern depends on position of hip at impact
Adult
More common than in children
Mechanism
High energy vs low energy
MVC
Fall from standing
Pattern depends on position of hip at impact
Pediatric more common in adolescents than younger children and more common high energy versus adults bimodal distribution and elderly much more commonly have low energy injury mechanism.
Unlike pediatric fx’s in other body regions, remodeling likely does not occur to a large degree

33. Classification Watts Type A Type B Type C Type D
Small fragment a/w hip dislocation
Type B
Nondisplaced a/w pelvic fx
Type C
Fx w/hip joint instability
Type D
Central fx/dislocation
Type D fx pictured
Image courtesy of Joshua Klatt , MD and Steven Frick, MD

34. Classification Bucholz Open triradiate cartilage
Acetabular growth abnormality frequent complication
Results in acetabular dysplasia, hip incongruity
Two injury patterns described
Shear Fx
Salter-Harris I or II
Thurston-Holland fragment may be visualized
Central displacement distal acetabulum
Crush Fx
Salter-Harris V
Narrow growth plate suggests injury
Worse prognosis, growth disturbance common
Bucholz, et al. Injury to the acetabular triradiate physeal cartilage. J Bone Joint Surg Am 1982;64(4):600-9.

35. Treatment Indications for operative treatment
Incongruent hip joint (fx fragment, labrum [MRI])
Displaced fx of weightbearing dome
Fx involving any displacement of triradiate cartilage
Joint instability

36. “Treatment Should Not Be Commenced Until a Full Understanding of The Fracture Is Achieved.”
Letournel

37. Treatment - Exposure
Surgical approach is chosen based on pattern of injury, displacement
Determine where you need to get direct access to in order to fix the fx, then choose approach based on that
Indirect access is often possible for reduction of AC through posterior approach, PC through anterior approaches
Reduction and fixation of wall fx’s requires direct access

38. Treatment - Exposure
Anatomic Location
Exposure(s)
Anterior Column
Anterior Intrapelvic Approach (AIP), Ilioinguinal, Smith Peterson (SP)
Anterior Wall
AIP, Ilioinguinal, SP
Posterior Column
Posterior approaches (ie. Kocher-Langenbeck [KL])
Posterior Wall
Posterior approaches (ie. KL)
Both Columns
Anterior or Posterior (typically side with greater displacement), Dual approaches, Extended Illiofemoral (rare)
**Standard posterolateral approach for hip arthroplasty is not the same as KL and not an acceptable approach for fixation of acetabular fx’s!

39. Treatment Heeg & Ridder (Clin Orthop Relat Res. 2000)
29 pts (2-16 y/o)
14 yr avg f/u
13 nonop
2 arthrotomy
14 ORIF
Satisfactory outcome in all pts with nondisplaced fx
21% fair or poor results
Central fx dislocation (Watts D) poor results
Heeg M, de Ridder VA. Acetabular fractures in children and adolescents. Clin Orthop Relat Res 376:80–6, 2000.

40. “The quality of the initial surgical reduction was the factor most commonly associated with the eventual development of posttraumatic osteoarthritis as well as with the eventual development of a fair or poor clinical outcome”
Matta J. Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. J Bone Joint Surg Am. 1996;78:

41. Complications Premature fusion of triradiate cartilage ~5%
Acetabular dysplasia
Shallow acetabulum
Hip subluxation
Image courtesy of Joshua Klatt , MD and Steven Frick, MD

42. Complications
Age is most important risk factor in the development acetabular dysplasia following pediatric acetabular fracture
Greatest risk is in children < 10 y/o at the time of injury
Bucholz, et al. Injury to the acetabular triradiate physeal cartilage. J Bone Joint Surg Am 1982;64(4):600-9.

43. Operative Treatment Late Reconstruction (Salvage)
Two case reports
Blair and Hanson: JBJS(A) 1979
Scuderi and Bronson: CORR 1987
Conservative management initially
Premature closure of triradiate cartilage
Symptomatic treatment
Chiari osteotomy 2 to 3 years prior to maturity
Slide courtesy of Joshua Klatt , MD and Steven Frick, MD

44. Operative Treatment Late Reconstruction (Salvage)
Conclusion:
Long-term results unknown
Salvage procedure
Chiari Osteotomy
Image courtesy of Joshua Klatt , MD and Steven Frick, MD

45. Summary – Peds Pelvic Fx’s
Stable fx’s can be treated nonoperatively
Unstable fx’s and those with > 2 cm displacement typically need surgical treatment
Low risk of VTE after pelvic fx in pediatric patients
Remodeling does not likely occur to an appreciable degree
>1 cm of pelvic asymmetry at time of healing will likely lead to chronic sequelae

46. Summary – Peds Acetabular Fx’s
Rare
Nonoperative treatment reserved for nondisplaced fx’s
In adolescents treat with similar principles as adult acetabular fx’s
In younger patients attempt smooth wire fixation when crossing physis
Follow closely for growth plate injury/physeal bar formation/dysplasia in young pts